basic health services

(1) The term “basic health services” means— (A) physician services (including consultant and referral services by a physician); (B) inpatient and outpatient hospital services; (C) medically necessary emergency health services; (D) short-term (not to exceed twenty visits), outpatient evaluative and crisis intervention mental health services; (E) medical treatment and referral services (including referral services to appropriate ancillary services) for the abuse of or addiction to alcohol and drugs; (F) diagnostic laboratory and diagnostic and therapeutic radiologic services; (G) home health services; and (H) preventive health services (including (i) immunizations, (ii) well-child care from birth, (iii) periodic health evaluations for adults, (iv) voluntary family planning services, (v) infertility services, and (vi) children’s eye and ear examinations conducted to determine the need for vision and hearing correction). Such term does not include a health service which the Secretary, upon application of a health maintenance organization, determines is unusual and infrequently provided and not necessary for the protection of individual health. The Secretary shall publish in the Federal Register each determination made by him under the preceding sentence. If a service of a physician described in the preceding sentence may also be provided under applicable State law by a dentist, optometrist, podiatrist, psychologist, or other health care personnel, a health maintenance organization may provide such service through a dentist, optometrist, podiatrist, psychologist, or other health care personnel (as the case may be) licensed to provide such service. Such term includes a health service directly associated with an organ transplant only if such organ transplant was required to be included in basic health services on April 15, 1985 . For purposes of this paragraph, the term “home health services” means health services provided at a member’s home by health care personnel, as prescribed or directed by the responsible physician or other authority designated by the health maintenance organization.


42 USC § 300e-1(1)

Scoping language

For purposes of this paragraph
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